Medical Management Nurse

Anticipated End Date:

2025-09-18

Position Title:

Medical Management Nurse

Job Description:

Medical Management Nurse

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. 

Work Schedule: Monday through Friday, 8:00am - 5:00pm, EST with alternating weekends and occasional holidays.

The Medical Management Nurse is responsible for reviewing the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of member’s clinical presentation to determine whether to approve requested service(s) as medically necessary. Works with healthcare providers to understand and assess a member’s clinical picture. Utilizes nursing judgment to determine whether treatment is medically necessary and provides consultation to Medical Director on cases that are unclear or do not satisfy relevant clinical criteria. Acts as a resource for Clinicians. May work on special projects and help to craft, implement, and improve organizational policies.

How you will make an impact:

• Utilizes nursing judgment and reasoning to analyze members’ clinical information, interfaces with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity.

• Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources.

• Determines and assesses abnormalities by understanding complex clinical concepts/terms and assessing members’ aggregate symptoms and information.

• Assesses member clinical information and recognizes when a member may not be receiving the appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.

• Provide consultation to the Medical Director on particularly peculiar or complex cases as the nurse deems appropriate.

• May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience.

• Collaborates with case management nurses on discharge planning, ensuring patients have appropriate equipment, environment, and education needed to be safely discharged.

• Collaborates with and provides nursing consultation to Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear.

• May participate in intradepartmental teams, cross-functional teams, projects, initiatives and process improvement activities.

• Educates members about plan benefits and physicians and may assist with case management.

• Collaborates with leadership in enhancing training and orientation materials.

• May complete quality audits and assist management with developing associated corrective action plans.

• May assist leadership and other stakeholders on process improvement initiatives.

• May help to train lower-level clinician staff.

Minimum Requirements:

• Requires a minimum of associate’s degree in nursing.

• Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years’ clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background.

• Current active, valid and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.

• Multi-state licensure is required if this individual provides services in multiple states.

Preferred Skills, Experience and Capabilities

• Clinical Experience is strongly preferred.  

• Compact Nursing License is highly preferred.

• Utilization Management Experience strongly preferred.

• Experience with Managed Care Plans preferred.

• Experience with provider communication is strongly preferred.

• Proficiency in Microsoft Office Suite (Excel, PowerPoint